The project will identify and characterize properties of infusion devices, environmental conditions, and operator cognition that promote "user error". The research will combine incident analysis with laboratory and field studies of devices in order to generate scenarios that can be used for assessments of existing devices and proposed designs. These scenarios will provide direct representations of the environmental characteristics, device features, and nature of operator cognition that combine to produce "user error". The research results will be directly available via the internet. users of the research will be able to trace the connection between incidents and scenarios and see the research work that links them. By demonstrating the links between characteristics of the devices, environments, and users, the project will advance the basic understanding of medical errors and patient safety. By exploring and presenting the details of how a particular information technology participates in high consequence failures, the project will provide a template that can be used to monitor and assess new and evolving healthcare technologies.